insurance information - P restige M edical, PA . DBA: S ai P rima ry

SAI PRIMARY CARE
PATIENT REGISTRATION FORM
Patient Name: ___________________________________________________________
Last
First
Middle
Date of Birth __________________Age: _____ Sex M / F Social Sec# ___________
Address: ________________________________________________________________
Street
City
State
Zip
Responsible Party Name: _______________________________DOB _______________
Address: ________________________________________________________________
Employer: ______________________________________WK Ph: __________________
Social Sec. # _____________________________________________________________
Home Telephone#: ___________________________ Cell Telephone #: ____________
Emergency Contact Person: ______________________ Telephone#: _______________
Relationship to Pt.: ________________________________________________________
How did you hear about us? _________________________________________________
INSURANCE INFORMATION
Name of Policy holder
Date of Birth:
PRIMARY INSURANCE –Effective: __/___/____ Secondary Insurance –Effective: ____/_____/____
Insurance Co. Name: ________________________
Group/ Plan # ____________________________
Policy/Member# __________________________
Subscriber Name: _________________________
Claim Address: ___________________________
____________________________
____________________________
____________________________
Insurance Co. Name: ______________________
Group/ Plan # ____________________________
Policy/ Member # _________________________
Subscriber Name: _________________________
Claim Address: ___________________________
____________________________
____________________________
The above information is true to the best of my knowledge. I authorize treatment for the individual above
or myself and I understand that I am ultimately responsible for changes associated with
medical services and authorize the physician and the clinic to release any information
required to process my insurance claims. I understand that my medical record may
contain information regarding HIV/AIDS, substance abuse, mental health, sexually
transmitted disease, sickle cell anemia, or other sensitive information. I also authorize my
insurance to directly pay The Prestige Medical P.A.
______________________________________________________________________________________
Patient/ Responsible Party Signature
Date
IMPORTANT
INFORMATION:
PARENTS PLEASE
BRING A COPY
OF YOUR CHILD’
S
SHOT RECORD
EVERY VISIT
IT WILL HELP US KEEP
THEM
UP TO DATE
SAI Primary Care
Acknowledgement –Notice of Private Practices (HIPPA)
Patient Name: _____________________________________
Date of Birth: ___________________Phone: ____________
Address: __________________________________________
City: ___________________State: __________Zip: _______
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2.
I understand the Health information Portability and accountability Act of 1996 (HIPPA) have
certain rights to privacy regarding my protected health information. I understand that this
information can be used to:

 Conduct, plan and direct my treatment and follow up among the multiple healthcare
providers who maybe involved in that treatment directly and indirectly.

 Obtain payment from third party payers.

 Conduct normal healthcare operations such as quality assessments and physician
certifications.
3.
The type and amount of information to be used or disclosed is as follows:
______ Complete health records __________ Labs results/X-ray reports
______ Physical exam
__________ Consultation reports
______ Immunization record
______ Other (please specify: _____________________________________
4.
5.
6.
7.
I understand that the information in my health record may include information relating to sexually
transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency
virus (HIV). It may also include information about behavior or mental health services and
treatment for alcohol and drug abuse.
I have received, read and I understand your Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my health information. I understand that this
organization has the right to change its Notice of Privacy Practices from time to time and that I
may contact this organization at any time to obtain a correct copy of the Notice of Privacy
Practices.
I understand that I may request in writing that you restrict how my private information is used or
disclosed to carry out treatments, payments or healthcare operations.
I understand that I have a right to revoke this authorization at anytime. I understand that if I revoke
this authorization I must do so in writing.
______________________________________
Signature of patient or legal representative
____________________________________
Signature of witness
Date: _________________________________
Date: _______________________________
PLEASE NOTE: This information has been disclose to you from confidential records protected from disclosure by state and
federal law. No further disclosure of this information should be done without written and informed release of the individual.
PRESTIGE MEDICAL P.A.-SAI PRIMARY CARE
3945 COUNTY ROAD 58, MANVEL, TX 77578
PATIENT AUTHORIZATION TO
DISCLOSE PERSONAL HEALTH INFORMATION
Patient: ___________________________________________________
(First Name)
(Middle Name)
(Last Name)
Address: __________________________________________________
Date of Birth: ________________
Prestige Medical P.A. Is authorized to furnish to / receive from (circle desired choice):
Recipient/Discloser: ________________________________________
Previous Dr. Name and Phone Number _________________________
For the Purpose of: ____ (continuing care) ______________________
_________________________________________
I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS:

Human Immunodeficiency Virus (HIV), alcoholism, I GIVE PERMISSION TO
RELEASE ALL MY MEDICAL RECORDS including information and records or copies of
records relating to the history, diagnosis, treatment or services rendered to m in connection with
any condition ore diseases. This includes permission to release POTENTIALLY SENSITIVE
INFORMATION which may include information concerning y treatment of illness, drug use/
dependency communications to social workers and/ or psychotherapies, psychologists, if any.

I GIVE PERMISSION TO RELEASE ONLY RECORDS
________________________________________________________________________
I release Prestige Medical P.A. and the Recipient/ Discloser listed above, and any of their
providers and staff from all responsibility or liability that may arise from the authorization. I may
withdraw this authorization at any time by giving written notification to Prestige Medical P.A.
provided that I do so in writing and to the extend that you have already disclosed the information
in reliance on this authorization
_________________________________________
Parent Signature (Parent’s Representative if minor)
_______________________
Date
_________________________________________
Witness Signature
_______________________
Date
PRESTIGEMEDCIALPA.COM
EMAIL: [email protected]
PH# 281-412-6606 Fax# 281-489-0233
Sai Primary Care
Pediatric Medical History Form
Date: ___________
Pa
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:__________________________________________________________
Date of Birth ____/___/____ Age: ______ Sex: M / F
Pr
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:________________________________________________
Office Phone Number: _____________________________Fax: ___________________
Allergies (include Medication, Insect bites/stings and common foods):
Medication
Food/Substance
Insect Bites
________________
____________________
_______________________
Current Medication: List the medications you are currently taking, also list any
Vitamins, Herbs, etc.
Medication Name
Dosage
Family History: Check the illnesses that have occurred in your immediate family.
Asthma
ADHD
Heart
disease
Mental
disorder
SickleCell
disease
Tuberculosis
Cancer
Father
Mother
Sibling
Personal History
ASTHMA
CHEST PAINS
HYPERTENSION
ADD/ADHD
CONSTIPATION
HEART ATTACK
ALLERGY
CONVULSION
HIV
ANEMIA
DEPRESSION
KIDNEY DISORDER
BED WETTING
DIABETES
LEARNING DISORDER
BIPOLAR DISORDER
DIZZINESS
MENTAL DISORDER
BLEEDING DISORDERS
DOWN’
SSYNDROME
RECENT TONSILLITIS
CARDIAC ARTHEMIA
FAINTING
STROKE
CANCER
ECZEMA
SICKEL CELL DISEASE
SUDDEN DEATH AT
EARLY
AGE
RECURRENT EAR
INFECTION
VESICO URETHRAL
REFLUX
TUBERCULOSIS
BLADDER INFECTION
THYROID DISORDER
The information is true to the best of my knowledge:
Patient/ Responsible Party Signature
Date
Sai Primary Care
Pediatric Medical History Form
Birth History: Vaginal Delivery __________
C- Section Delivery _______
Developmental History: Sitting at _____Months
____Months
Walking _____ Months
Talking Few Words at
climbing _____Months
Chickenpox ______Yes Date: ____________ No ______________________________
Surgery: ________________________________________________________________
Immunization c
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Is the patient having problems in any of the following
 behavior
 interaction with peers school performance?
Please describe:
______________________________________________________________
Is there any indication f past or present use of the following?
Tobacco
Yes
__
No
___
If yes, please note frequency below
_______________________________________
Alcohol
__
____
_______________________________________
Controlled substance
__
___
_________________________________
The information is true to the best of my knowledge:
Patient/ Responsible Party Signature
Date
SAI PRIMARY CARE
PATIENT REGISTRATION FORM (CONT)
Sai Primary Care is committed to providing you with the best possible care.
If you have medical Insurance we are eager to help you receive your maximum
Allowable benefits. In order to achieve these goals, we need you assistance,
And you understanding of our payment policy.
1.
CONTRACTED INSURANCE: All insurance companies are billed
Directly as a courtesy. Any remaining balance for non-covered benefits and deductible are your
responsibility. Payment for this is expected within 30 days from receipt of your statement.
2.
CO-PAYS: All co-pays are expected at the time the service is rendered.
3.
NON-CONTRACTED INSURANCE: If your insurance company is not contracted with SAI
Primary Care will provide you with a claim to sent to your insurance fore reimbursement. All
Third Party Payers (motor vehicle accident insurance) are considered non-contracted.
4.
METHOD OF PAYMENT: We accept cash, checks VISA, MasterCard or Discovered
5.
PAYMENT ARRANGEMENTS: We understand that there may be times when financial
difficulties come upon us without warning. Under special circumstances temporary payment
arrangements may be made if approved in advance. Accounts on a temporary payment plan are
required to make payment each and every month. Missed payments could result in collections.
Accounts on a payment plan also must continue to pay at the time of the services. Our goals are to
help you from attaining a greater debt and to assist you by keeping your account at a manageable
level.
6.
RETURN CHECKS: There will be a $25.00 charge for all return checks.
7.
SERVICE FEE: There is an interest fee accrued on ALL accounts with balances 60 days and over,
regardless of payment arrangement or secondary insurance statue.
8.
DIVORCED, SEPARATED, OR BLENDED FAMILIES: In order to keep accounts clean and
eliminate any embarrassing or uncomfortable situation for you, we have chosen NOT to become
involved in any agreements, understanding, and/or court order regarding reimbursement from the
absent parent. Payment is required at the time of service. Reimbursement from absent parent is
your responsibility.
9.
NO SHOW/CANCELLATION POLICY: There may be a fee for no-show appointments or
cancellation of appointments with 24-hour notice.
If you have any questions about the above information or any uncertainly regarding insurance
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Patient/Responsible party Signature
Date
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD
IMMUNIZATION REGISTRY (ImmTrac)
CONSENT FORM
REGISTRO DE INMUNIZACIÓN (ImmTrac)
FORMULARIO DE CONSENTIMIENTO
(Please print clearly / Sirvase escribir claramente con letra de molde)
For Clinic/Office Use
Child’s Last Name / Apellido del niño(a)
Child’s First Name / Nombre del niño(a)
/
/
Child’s Middle Name / Segundo nombre del niño(a)
*Children under 18 years only /
Solamente niños menores de 18 años
Child’s Gender / Género:
Male / Masculino
Female / Femenino
Child’s Date of Birth / Fecha de nacimiento del niño(a)
Child’s Address / Dirección del niño(a)
Apartment # / Apartamento #
City / Ciudad
State / Estado Zip Code / Código postal
Mother’s First Name / Nombre de la madre
Telephone / Teléfono
County / Municipio
Mother’s Maiden Name / Apellido de soltera de la madre
ImmTrac, the Texas immunization registry, is a free service of the Texas
Department of State Health Services. The immunization registry is a secure
and confidential service that consolidates and stores your child’s (under 18
years of age) immunization records. With your consent, your child’s
immunization information will be included in ImmTrac. Doctors, public health
departments, schools and other authorized professionals can access your child’s
immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages
your voluntary participation in the Texas immunization registry.
El registro de inmunización (ImmTrac) de Texas, es un servicio gratis que proporciona el
Departamento Estatal de Servicios de Salud. El registro de inmunización es un servicio
seguro y confidencial que consolida y guarda el récord de inmunizaciones de su niño
(menor de 18 años de edad). Con su consentimiento, la información de la inmunización de
su niño será incluida en ImmTrac. Los doctores, departamentos de salud pública, escuelas
y otros profesionales autorizados pueden tener acceso al historial de inmunización de su
niño para asegurar que las vacunas importantes no le falten.
El Departamento Estatal de Servicios de Salud le anima a
participar voluntariamente en el registro de inmunización de Texas.
Consent for Registration of Child and
Release of Immunization Records to Authorized Entities
Consentimiento Para Registrar al Niño(a) y Para Poder Dar a Conocer a
Entidades Autorizadas el Récord de Inmunizaciones del Niño(a)
I understand that by granting consent below, I register my child in the Texas
Department of State Health Services immunization registry and authorize the
registry to include my child’s information in the registry and to release past,
present, and future immunization records on my child to a parent of the child
and any of the following:
• public health district or local health department;
• physician or health care provider;
• insurance company, health maintenance organization or payor;
• school or child care facility in which the child is enrolled and/or
• state agency having legal custody of the child.
I understand that I may withdraw the consent to include information on my
child in the ImmTrac Registry and my consent to release information from the
registry at any time by written communication to the Texas Department of
State Health Services, Immunization Registry, 1100 West 49th Street, Austin,
Texas 78756.
Entiendo y acepto que al autorizar mi consentimiento en la parte inferior, registro a mi
niño(a) en el registro de inmunización del Departamento Estatal de Servicios de Salud de
Texas y autorizo al registro para que incluya la información de mi niño(a) en el registro y
que el récord de inmunizaciones de mi niño(a) del pasado, presente y futuro sea dado a
conocer a alguno de los padres del niño(a), y a cualquiera de los siguientes:
• distrito de salud pública o departamento de salud local;
• médico o proveedor de atención de salud;
• compañía de seguros, organización para el mantenimiento de salud o pagador;
• escuela o centro de cuidado de niños, en el que el niño(a) está inscrito y/o
• agencia estatal que tenga custodia legal del niño.
Reconozco y acepto que en cualquier momento puedo retirar mi consentimiento de poder
incluir la información de mi niño(a) en el Registro ImmTrac, y también retirar mi
consentimiento para poder dar a conocer la información del registro, por medio de
comunicación escrita dirigida al Texas Department of State Health Services,
Immunization Registry, 1100 West 49th Street, Austin, Texas 78756.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry.
Al firmar abajo, YO AUTORIZO el consentimiento para registrarlo. Deseo INCLUIR la información de mi niño en el registro de inmunización de Texas.
Parent, legal guardian, or managing conservator:
Alguno de los padres, tutor legal o administrador de bienes:
_______________________
Date / Fecha
____________________________________________________________
Printed Name / Escriba con letra de molde
_______________________________________________________________________________________
Signature / Firma
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the
State of Texas collects about you. You are entitled to receive and review the information upon request. You also
have the right to ask the state agency to correct any information that is determined to be incorrect. See
http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section
552.021, 552.023, 559.003 and 559.004)
Notificación Sobre Privacidad: Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado
sobre la información que el Estado de Texas reúne sobre usted. A usted se le debe conceder el derecho de recibir y revisar la
información al requerirla. Usted también tiene el derecho de pedir que la agencia estatal corrija cualquier información que se ha
determinado sea incorrecta. Diríjase a http://www.dshs.state.tx.us para más información sobre la Notificación sobre privacidad.
(Referencia: Government Code, sección 552.021, 552.023, 559.003 y 559.004)
Questions? / ¿Tiene preguntas? (800) 252-9152 • (512) 458-7284 • www.ImmTrac.com
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347
Stock No. C-7
Revised 07/17/07
PROVIDERS REGISTERED WITH ImmTrac – please fax this
signed (by parent) Consent Form to ImmTrac
only if the child is not currently registered with ImmTrac.
Fax to: Toll free (866) 624-0180